By-Dhiraj Singh :On a rainy night of September 2007, Taru Kalita, started having labour pains. When her situation deteriorated, her husband went out of the hut and, in an act of not so rare escapism, simply disappeared in the night. When Taru noticed the absence, her first response was to inform the local Accredited Social Health Activist (ASHA) Susmita Kakoti of her Sub Centre (Mazirgram of Kamrup district, Assam). The ASHA arrived on the scene and she could see that Taru was in the critical condition, which needed professional care. She took charge of the situation and decided to take the lady to nearby Primary Health Centre (PHC) in Azara block. Taru had no money with her, so the ASHA took Rs 500 loan from her Self Help Group and took the mother to the PHC.
Taru gave birth to a boy and received professional care which saved the lives of her and the newborn child. She received Rs 1400 under the Janani Suraksha Yojna and other schemes. She returned Rs 500 to Susmita so that she could repay her loan. The husband was tracked and was counseled by the ASHA about his responsibilities towards the wife. This was a case where ASHA went beyond the call of duty and saved lives. However, this attitude is ingrained in the concept of ASHA which is designed as the driving force of the flagship programme of National Rural Health Mission (NRHM).
Launched in April 2005, NRHM aims to provide accessible, affordable and quality healthcare to the rural population, especially to the vulnerable sections. The Mission has shifted focus from vertically designed schemes and programmes to the development of the state health system. The philosophy of NRHM is to move from distrust to trust. The Mission provides resources and flexibility at an unprecedented level and gives states flexibility to take up the areas of health sector such as physical infrastructure, human resource, equipments capacity-building or skill upgradation. The Mission lays special emphasis on reduction in Maternal Mortality, Infant Mortality and Total Fertility Rate. Union Minister for Health and Family Welfare Dr Anbumani Ramadoss says, “the most important intervention under the Mission is the introduction of trained community level workers in the form of ASHA”. Truly, ASHA is envisaged as the link between community and health system, who reinforces action for universal immunization, safe delivery, newborn care, prevention of communicable diseases, improve nutrition and promotion of household toilets. She informs, interacts, mobilizes and facilitates improved access to preventive and promotive health care and also provides basic curative care through her Drug Kit. Thus ASHA is village health activist, counselor, and catalyst agent for healthy practices. As is clear from the case of Taru, ASHA promotes institutional child delivery. She arranges escort or accompany pregnant women and children requiring treatment or admission to the nearest pre-identified health facility i.e. Primary Health Centre/ Community Health Centre/ First Referral Unit (PHC/CHC /FRU) for which compensation is built into the Janani Suraksha Yojana. This is major incentive mechanism in the ASHA scheme. “I could see the joy of the mother after child birth, which I consider my best reward” said Kusum Baishya another ASHA in the Azara block.
Empowerment Through Service
ASHA is also a mechanism of women empowerment. An active ASHA becomes a valued community figure and her contribution is rewarding both financially and from the point of view of inner satisfaction. Chayaran Nessa, ASHA of Khilorbond village under Burunga Gaon panchayat of Karimganj district of Assam started crying with happiness while describing the changes brought about by her selection as ASHA. Her hard work made her indispensable for the health efforts in the village, her status in her family improved and she earned enough to buy little land, “activities that I perform as ASHA have given new meaning to my life” says Nessa. An Army of more than 5.5 lakh ASHAs is feeling the transformative power of responsibility and status. Most of these ASHAs have received induction training, study modules, special training such as Malaria related course in Assam and Drug Kit. Many states have given radio sets to ASHAs and there are radio programmes for ASHAs. Main purpose of these radio programme is to update knowledge of the ASHA regarding her various activities and above all to motivate her voluntary social work.As a promoter of good health practices in the community she plays a crucial role in the outreach efforts of the government dealing with minor ailments and making timely referrals. Her responsibilities are increasing as she acts as the depot holder of the essential health supplies and maintains a register of births and deaths. The burden is not light and incentives are not very lucrative at this stage. ASHAs have expressed dissatisfaction with the compensation mechanism and sometimes delay in payments. Some have said that ASHAs should be paid for helping institutional deliveries irrespective of public or private nature of the institution. There are cases of resentment against the amount and delivery of compensation.
However, ASHAs are gradually getting their due. Rs. 10000/- per ASHA is being provided for the purpose of training and handholding. Another innovation that has been brought in is the service delivery based compensation for the ASHA, which provides immense opportunities to well performing ASHAs to supplement their income. Dr Ramadoss have cautioned, “if it has to be sustainable, the ASHA has to be perceived as a service delivery agent and not a commission agent. Incentives have been built into the Janani Suraksha Yojana (JSY), Immunisation, Malaria and other schemes to provide the ASHA with adequate compensation.” Decision to purchase bicycles for ASHAs have been delegated to local levels, apart from Radio they have been given umbrellas. Many ASHAs complained of their efforts going waste in case of poor facilities at the health centres at the local level. This is improving with greater allocation and better monitoring. A web based ASHA Information and Management System is also envisaged by the Ministry of Health and Family Welfare.
ASHAs are the key strategic intervention to successfully change the health landscape of the country for better. Inclusive growth entails accessible health care for everyone. Investment in the health sector for a very long time stagnated at less than one per cent of the GDP, with NRHM things are improving and ASHA are the most visible face of this transformation. They represent public health system at the cutting edge level. They are the interface which lays the foundation of successful implementation of policies and making health sector regeneration a national enterprise. They are the basic building block of the NRHM- a unit of hope.
*Joint Director (M & C), PIB, Delhi